29 March 2006

I just got the discharge report for the little boy I posted about here. Not only did he survive, he did very well. It's amazing. I thought he was a goner for sure. He has some neurologic deficits, a partial hemiparesis of some sort, which is a pity but it sure beats a very small coffin! Most importantly, the rehab report describes him as "alert, oriented, and conversational"! Woo-hoo!

So often, what I doo seems pointless -- most of the folks I see have no actual disease, or the trajectory of their disease is going to continue regardless of any intervention I perform. And of course, it is too rare for me to get feedback on the outcomes in cases. Thus, the job can seem to be reduced to . . . moving meat. So it's really a thrill to hear about a truly terrible, tragic case that had a happy ending. Not that I did anything too earth-shattering in it, but I was the inflection point in the arc of his illness where the trajectory turned from moribund to improving, so I feel justifiably proud and part of the miracle.

23 March 2006

Betsy was 85 years old, living independently, and in near-perfect health. Her daughter brought her in when she abruptly became short of breath. I saw her with her three adult daughters at the bedside. She was a bit gray, had labored breathing, with an irregular pulse at 135, and hypoxic. She certainly looked critically ill, but was cheerful and as talkative as the circumstances permitted. Her oldest daughter was a CCU Nurse Supervisor. I went over the differential with her – MI, Pulmonary Embolism, Atrial Fibrillation, Congestive Heart Failure, Pneumonia – and sent off a slew of labs. Her EKG was fast but unexciting, and her chest x-ray was essentially normal. Labs came back unusually quickly, and were unremarkable except for a mildly elevated Troponin, a heart enzyme indicative of a heart attack in progress. Just then the nurse told me that her EKG had changed and that Betsy had developed severe chest pain.

Sure enough, a repeat EKG showed an obvious, massive heart attack in progress, with marked ST elevation. This was actually a good thing, since a) now I knew what was going on, and b) it was treatable. I discussed the options with the family, and they indicated that they wanted the full treatment, so after quick call to the on-call cardiologist, who was dubious but professional, the cardiac cath lab was called in. I wrote the standard orders – morphine, beta-blocker, heparin, etc – and moved on to the next patient in the queue. The Emergency Department was just swamped, with waiting times over three hours. No sooner had I finished examining a young lady with pneumonia than I was paged overhead stat to Betsy’s room.

When I got there, she was dead. Unmistakably so. Her skin was waxen and yellow, and she was not breathing; the monitor reflected a heart rate of 30, but I knew that there would be no pulse if I checked her wrist. It is amazing how obvious it can be when the vital force has departed a body. Taking this in a fraction of a second, I reflexively said “Well, this isn’t good.” Her daughters looked at me with tears in their eyes and the eldest said “We know. We’re okay with it.” I turned off the cardiac monitor and removed the oxygen mask from her face. A few words of condolence and I left them alone. I called the cardiologist back, a bit ruefully, and cancelled the case. We called the chaplain, and I moved on back into the realm of the living.

It’s a bit curious. I’ve always said: “As an ER doctor, most of my patients come in alive and will leave alive no matter what I do; a few come in dead and leave dead. Rarely someone comes in dead and leaves alive, which is a victory, and occasionally someone comes in alive and leaves dead, which I take as a personal offense.” But in this case I wasn’t offended. It was the most natural, wholesome (if there can be such a thing) death I have ever been privileged to witness. It was quick and relatively painless, the whole family was there, and everybody was emotionally in tune with it. I hope I go as well. I’m still kind of shocked at how quick it was. As an ER doc, I see a lot of death, and it’s usually more of a process than an event, and there’s usually a longish time between when it begins and when it is irreversible. Not so with Betsy. There one minute, gone the next.

18 March 2006

The official story was that it was a ricochet, though it surpasses credulity to see how such a thing could occur. Yet it has happened, not just once, but apparently at least twice, as previously reported here.

Unfortunately, this poor fellow who came to our ED was worse off than the gentleman from Colorado who suffered the same injury but apparently did very well. This nail seems to have been somewhat longer and went in more orthagonally, transfixing the left eyeball, from below. The brain was not penetrated. To our surprise, he actually had quite good vision in the left eye as measured by a handheld snellen chart -- about 20/50. He could still move the eyeball from side to side, though his acuity worsened when he did.

He was transferred to the local trauma center, where I presume he required enucleation.

15 March 2006

Beth and I packed all the kids in the van and headed out. We had an "only a mom would do this" moment when one of the children had to pee while we were stuck in traffic. There was an aborted attept to use a water bottle and a successful pee into a mug while driving along.

Beth commented that she might get a wide-mouthed container to keep in the car in the event that should happen again. I was thinking about the urinals we use in the ER (which are cappable), but then it occurred to me that a MUCH better product is available. We usually stock these in the cockpits of the airplanes I fly, and I have used them with success. Ladies and Gentlemen, I present to you, the TravelJohn:

It's full of that super-absorbent stuff you find inside diapers, and you can put an amazing amount of pee in it, and it doesn't spill or stink. Now that I think of it, I am going to order a few for our cars.

14 March 2006

I stopped by the QFC store this evening after Karate looking for some Gatorade, as I was a bit dehydrated. What did I find in the Beverage aisle but a six-pack (just one on the shelf) of Sierra Nevada India Pale Ale. For those of you not so into beer, know that Sierra Nevada is a truly first-rate large brewery that makes several of my favorite beers (celebration ale, and the best large-brew porter around) and the IPA is my favorite style of beer. I didn't even know that Sierra Nevada made an IPA. Oh joy.

For the record, I found it excellent, creamy and smooth, malty and a little fruity, well-hopped but not overpoweringly so. My perception on this may be skewed since I am used to some local IPAs which are so hoppy that they will sear your palate clean off.

I also picked up a regular favorite of mine, the Smoked Porter out of Stone Brewing in San Diego (pictured). Really full-bodied and robust -- very rich, almost like a stout. Hints of chocolate and coffee, smoky but not heavily so. I could drink this all night.

"Beer is living proof that God loves us and wants us to be happy." Benjamin Franklin

11 March 2006

This is not a new development, per se. It is, however, the first time this ugly little beast has reared its head in Washington State, and I am sorry to see it. It personally makes me angry. I do not see how pharmacists, who I generally respect as health care professionals, get off carving out a 'conscientous objector' exemption to providing care to certain persons of whom they disapprove.

Perhaps it is my own background that makes me so sensitive to this issue. I am compelled, both ethically and legally, to provide care to a great many persons whom I dislike or disapprove of. I have cared for Neo-nazis, drug users, spousal abusers, child abusers, felons great and petty; I have cared for individuals who have insulted me and assaulted and injured my staff; I have cared for individuals whose behavior I found deeply immoral and objectionable. I have no legal exemption to refuse to provide them with health care, nor would I claim such a right were it a legal option for me. Because it would be wrong.

When you sign up to become a physician, to a certain extent it means you have to check your personal prejudices at the door. When you are the provider of medical care, you are in a position of power, and the patient is at their most vulnerable. If you are providing a service which is urgent and/or not readily available elsewhere, your duty to the patient is at its highest, and any threat to withold that care is abusive. To be sure, in a non-urgent setting, or for services which are readily available elsewhere, I have no problem with a doctor saying that for personal reasons he or she cannot care for a given individual or provide a particular service. But it is an ethically dicey matter to do so, and must be done in a manner which is consistent primarily with the patient's best interests and only secondarily with the provider's personal values.

The pharmacists have little ground to claim any such exemption. Their involvement with the patient's care in these cases is minimal and their relationship with the patient is superficial at best. Their power, however, is disproportionately magnified, since they have the ability to refuse to allow the patient to fill a prescription written by a provider with whom the patient has a stronger relationship. In essence, the pharmacist has little involvement in the decision-making process, yet for some reason feels they should be able to exercise a veto. And one should not assume that, refused at one pharmacy, that patients will necessarily be able to fill their prescriptions at another nearby one.

Now I am not dissing pharmacists -- many an alert PharmD has prevented me from making errors or helped with a difficult case. But that some pharmacists are upset about abortion or feel that it is wrong: I am not particularly sympathetic. The principle of patient autonomy and self-determination should trump their (and my) delicate sensibilities about what we feel is right for the patient. We as health care providers can guide patients to make good decisions, we can provide information and counsel, but we cannot project our own values onto patients in their hour of need.

And it is even more irritating that I suspect that this is an issue not truly because there are a lot of pharmacists who truly feel that their consciences are being violated, but rather that the right wing has found themselves a new wedge issue to play politics with health care.

07 March 2006

Kim over at Emergiblog has this week's Grand Rounds up. Check it out, if only for the awesome retro artwork, but stay for the many interesting posts. It'll take me all week to sort through the lot of 'em.

I've been seeing a lot of buzz building in the blogosphere about universal health care as the best and possibly only solution for our broken health care system. It's heartening, because I have been a strident advocate for some sort of universal coverage for quite some time now. I don't know what sparked the conversation, but I'm glad to see it happening. Maybe it was Krugman's excellent piece at the New York Book Review, or Kevin Drum over at Washington Monthly. But the domino effect took hold and within a couple of days we were seeing Greg Anrig at TPM Cafe and Ezra Klein, followed by Kate at Healthy Policy and Matt Yglesias pile on the bandwagon. (Not that any of these folks are newcomers to the church of Universal Health -- but they were all talking about it at once.) They debate single payer vs multiple payers, incremental vs comprehensive reform, political strategy and obstacles to overcome, political risks and opportunities, oh my. Heady times. Add to that the fact that Massachusetts just approved a modest reform of its health plan, and you could almost deceive yourself into thinking that maybe there is a little momentum building, that just possibly, if people keep talking about this and the publicity builds, and maybe we've got a real thing here.

Then reality reasserts itself and you realize that with the current party controlling the federal government, there's no chance.

For that matter, the Democrats have't been forward on this issue either. As has been pointed out in many places, they are still in shock over the ugly demise of HillaryCare twelve years ago, and I cannot think of a single national-stature democrat who has advocated for this policy. I think its time is coming, maybe not yet as policy enacted into law, but as a hell of a political wedge issue. There are a lot of folks out there with growing anxiety about the cost and durability of their health care coverage, and a lot of folks with none at all. This is the Democrats' answer to the right's relentless drumbeat of tax cuts tax cuts tax cuts. . .

And Universal Health is the right thing for America, on many levels:

It's better for our economy because it would be more efficient and reduce wasted healthcare dollars - up to 3 percent of the GDP.

It would make American businesses more competitive in the international market by reducing the staggering health care costs employers have to pay.

It would provide American workers the ability to switch jobs without risking losing essential health care coverage.

It would remedy the logical non sequitur that your healthcare depends on your employment status.

It would strengthen the economy by improving the health of many marginal individuals and allow them to return to the workforce.

It would end the cost-shifting that doctors and hospitals have to go through to offset the costs of uncompensated care, and would increase the fairness of the pricing system.

Most importantly, it's a moral necessity to ensure all our citizens have access to medical care and to eliminate the underclass 40-to-90 million strong who are un- or under-insured.

I think this has to be the Democrats' core issue if they are ever to have any chance of being allowed back into power by the voters. We have to prove that there is something that we care about and are willing to fight for through several election cycles. This issue is not going to go away. The costs of healthcare continue to rise and the pressure on industry to contain expenses will rise in lockstep, and as they do, the number of uninsured will continue to soar and the expenses for medicaid will also climb. The medical system is in crisis, and until a solution is implemented it is going to continue to get worse. And it will represent a huge opportunity for the Democrats to prove that we deserve the reins of government. If we do nothing, the cost in lost opportunity and in human suffering will be staggering.

03 March 2006

I'm on day four of a nasty upper respiratory illness that has left me prostrate and bed-ridden. I am persistently running fevers of 102 and up. I finally broke down and got some antibiotics, and admitted that I should not be working. I tried to work today, which was a mistake. I was able to get through the shift but it was miserable.

I've always had a special sympathy for people with fevers. When I see someone who is febrile, not only is it a cue that they really have something wrong with them, they so clearly look ill that it's impossible not to want to make them feel better. Most everybody I see with a fever, I'll at a minimum pop in an IV and given them a liter of fluid. It usually is not medically indicated per se, but you know there is an obligate fluid loss that comes with a fever, and I really believe that dehydration makes the fever feel so much worse, so I do it anyway. People seem to perk up with fluids, so I've got to take that as evidence that the dehydration is a big factor in the wretchedness. I kind of wish that someone were here to give me some IV fluids. When I was a resident, we used to do that for each other -- bring over an IV set-up to a co-resident's place when they were puking. Though that generally tended to follow a night at the bars. But I am making do with Gatorade -- wonderful stuff. I still am exhausted and ache from head to toe, but slowly I improve.

"Now this may hurt a little . . . actually it's going to hurt rather a lot."

For patients with a medical diagnosis:

"There's Good News and Bad News. The Bad news is you have [X]. The Good news is that it's you and not me."

"Everybody's got to die sometime."

Now, I've never said (most) anything on this list, but I have a wicked mind and have thought about it on many occasion. I'm sure you have thought about it, too. Feel free to add suggestions in the comments.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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